SDOH
Loren Bonner
Pharmacists are primed to address social determinants of health (SDOH) in patients with diabetes. According to CDC, 50% of U.S. adults with diabetes report financial stress and about 20% of U.S. adults with diabetes experience food insecurity.
“The numbers that look at health outcomes related to SDOH are really kind of jaw-dropping,” said Erin Pauling, PharmD, BCACP, who presented on the topic of SDOH’s impact on diabetes at APhA2022 in San Antonio, TX. “They indicate that only about 10% to 20% of health outcomes are due to medical care. Conversely, that means that 80% to 90% of outcomes for our patients have nothing to do with the medical or pharmaceutical care we are providing.”
As pharmacists become more aware of the importance of SDOH on their patients’ health outcomes—or the “non-medical factors that influence health outcomes”—they need to be familiar with tools and resources they can use in practice to assess and mitigate SDOH.
During the presentation, Pauling, along with Megan Coleman, PharmD, BCPS, touched on some of the available screening tools for SDOH generally, and for SDOH and diabetes specifically.
“It’s important to know that there is not one single tool that is preferred over the other,” said Coleman, who is an associate professor of pharmacy at Wingate University School of Pharmacy. “It’s really what is going to fit you and your practice and your patient population. Also important to know [are that] these screening tools can be administered by clinical or non-clinical staff, or patients can self-administer these as well.”
She noted that patients may be more likely to disclose sensitive information if they self-administer.
Screening tools for SDOH
- The EveryONE Project from American Academy of Family Physicians.
- PRAPARE: Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences.
- The Accountable Health Communities Health-Related Social Needs Screening Tool from CMS.
Some of the tools have different languages available, but they all cover the 5 core SDOH domains: education access and quality; health care access and quality; neighborhood and built environment; social and community context; and economic stability.
During the presentation, Pauling and Coleman only had time to discuss diabetes SDOH tools for health literacy and numeracy (under the SDOH category of health care access and quality), and food insecurity (under the SDOH category of economic stability).
“We can’t touch on all the elements in this presentation, but we want to focus on elements you might want to consider in your pharmacy practice settings to be able to have some tools and resources at your disposal to be able to address health literacy and numeracy as well as food insecurity,” said Pauling, who is a clinical assistant professor of ambulatory care at Binghamton University School of Pharmacy and Pharmaceutical Sciences in New York.
Resources to address health literacy and numeracy
- Agency for Healthcare Research and Quality (AHRQ) Health Literacy Universal Precautions Toolkit
- Diabetes Literacy and Numeracy Education Toolkit (DLNET)
- Partnership to Improve Diabetes Education Toolkit (PRIDE)
Health literacy and numeracy
Health literacy and health numeracy can affect a person’s diabetes complications, disease state understanding, glycemic control, lifestyle modifications, and medication-taking behaviors, for example.
“[But] if we are using a screening tool and assessing a patient and determining if maybe there is a limitation or problem, that is not enough,” said Coleman. “In fact, that is probably worse if you are not going to address it in some way and provide some resources.”
What screening tools do we have available for health literacy and numeracy?
General screening tools
- Newest Vital Sign (NVS)
- Rapid Estimate of Adult Literacy in Medicine (REALM)
- Rapid Estimate of Adult Literacy in Medicine, Revised (REALM-R)
- Single Item Screener
- Subjective Numeracy Scale
- Shortened Subjective Numeracy Scale
Diabetes-specific screening tools
- Diabetes Numeracy Test
- Literacy Assessment for Diabetes
Food insecurity
Food insecurity is defined as the inability to access food because of inadequate finances and other resources.
“A range of behaviors go along with this like feeling anxious to skipping meals,” said Pauling.
She said that based on the data available currently, about 20% of patients with diabetes report food insecurity.
“We know food insecurity is a risk factor for poor diabetes management,” said Pauling. Most patients are consuming inexpensive, energy dense foods. Many also experience frequent periods of inadequacy to purchase food.
“For hyperglycemia and diabetes this means increased blood sugars with inexpensive energy dense foods. Or binging when food is available,” said Pauling. “Also patients will commonly forgo certain medications to put food on the table.”
What screening tools do we have available for food insecurity?
- USDA Food Insecurity Surveys
- Hunger Vital Sign
“One of the most important things we can do as pharmacists is have readily available a list of local resources,” said Pauling. ■
Resources for food insecurity
List of local food resources and contacts—food banks/pantries, soup kitchens, and free meal delivery programs.
Food pantry locators
- Hunger + Health & Feeding America
- Foodpantries.org
- Pantrynet.org
- Ample Harvest
- Food Finder
Nonprofit organizations
- WhyHunger
- 211
- Findhelp.org, by Aunt Bertha
- The EveryONE Project Neighborhood Navigator
Collaboration with community partners/resources (“Food prescriptions,” community gardens, food pharmacies)
For pharmacists who are interested in learning how to use the Pharmacists’ Patient Care Process to address SDOH in patients with diabetes, please refer to the recent article in JAPhA: doi.org/10.1016/j.japh.2022.01.008